The effect of postoperative CPAP use on anastomotic and staple line leakage after bariatric surgery

Effect of noninvasive respiratory support after extubation on postoperative pulmonary complications in obese patients: A systematic review and network meta-analysis

STUDY OBJECTIVE

Obesity is associated with an increased risk of sleep-disordered breathing (SDB) and postoperative pulmonary complications (PPCs). Postoperative noninvasive respiratory support (NRS) has been recommended to obese patients despite the controversy about its benefit. The network meta-analysis (NMA) was used in this study to compare the effect of different methods of NRS on preventing PPCs in obese patients.

DESIGN

This study is a network meta-analysis.

SETTING

Post-anesthesia care unit and inpatient ward.

PATIENTS

20 randomized controlled trials involving 1184 obese patients were included in the final analysis.

INTERVENTIONS

One of the four NRS techniques, which include continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), high-flow nasal cannula (HFNC), or conventional oxygen therapy (COT), was performed after general anesthesia.

MEASUREMENTS

The primary outcome was the incidence of PPCs, e.g., atelectasis, pneumonia, hypoxemia, and respiratory failure. The secondary outcomes included the incidence of oxygen treatment failure and anastomotic leakage, oxygenation index, and length of hospital stay (LOS). RevMan 5.3 and STATA 16.0 were used to analyze the results and any potential bias.

MAIN RESULTS

Compared with COT, BiPAP and HFNC were both effective in reducing the occurrence of postoperative atelectasis. There were no significant differences in the occurrence of other PPCs including pneumonia, hypoxemia and respiratory failure between the four NRS techniques. CPAP and HFNC were superior to other techniques in improving oxygenation and shortening LOS respectively. No differences were found in oxygen treatment failure and anastomotic leakage between the patients with different NRS. HFNC ranked the first in five of the eight outcomes (hypoxemia, respiratory failure, treatment failure, anastomotic leakage, LOS) in this review by the surface under the cumulative ranking curve (SUCRA).

CONCLUSION

Among the four postoperative NRS techniques, HFNC seems to be the optimal choice for obese patients which shows certain advantages in reducing the risk of PPCs and shortening LOS.

Bariatric surgery and obstructive sleep apnea: a systematic review and meta-analysis

BACKGROUND

Several studies evaluated the effect of bariatric surgery on obstructive sleep apnea (OSA) but findings have been inconsistent. The aim of this study was to conduct an updated systematic review and meta-analysis to investigate the effect of bariatric surgery on OSA.

METHODS

The databases for PubMed, CENTRAL, and Scopus were searched up to the 1st of December, 2021. Studies were included if they were cohort or case-control in design, included patients with diagnosis of OSA, the patients underwent any bariatric surgery, and the study performed postoperative polysomnography.

RESULTS

The total number of the included patients was 2310 patients with OSA from 32 studies. Our analysis showed that bariatric surgery was associated with significant reduction in BMI (WMD =  - 11.9, 95%CI: - 13.4, - 10.4), apnea-hypopnea index (AHI) (WMD =  - 19.3, 95%CI: - 23.9, - 14.6), and respiratory disturbance index (RDI) (WMD =  - 33.9, 95%CI: - 42.1, - 25.7). The rate of OSA remission after the surgery was 65% (95%CI: 0.54, 0.76).

CONCLUSION

Our results suggest that bariatric surgeries are effective in reducing obesity among patients with OSA in addition to OSA severity measures. However, the low rate of OSA remission suggests that the main etiology of OSA is not only obesity but also includes other important variables such as the anatomy of the jaw.

The effectiveness of positive airway pressure therapy in reducing postoperative adverse outcomes in surgical patients with obstructive sleep apnea: A systematic review and meta-analysis

IMPORTANCE

Obstructive sleep apnea (OSA) is prevalent in surgical patients and is associated with an increased risk of adverse perioperative events.

STUDY OBJECTIVE

To determine the effectiveness of positive airway pressure (PAP) therapy in reducing the risk of postoperative complications in patients with OSA undergoing surgery.

DESIGN

Systematic review and meta-analysis searching Medline and other databases from inception to October 17, 2021. The search terms included: "positive airway pressure," "surgery," "post-operative," and "obstructive sleep apnea." The inclusion criteria were: 1) adult patients with OSA undergoing surgery; (2) patients using preoperative and/or postoperative PAP; (3) at least one postoperative outcome reported; (4) control group (patients with OSA undergoing surgery without preoperative and/or postoperative PAP therapy); and (5) English language articles.

PATIENTS

Twenty-seven studies included 30,514 OSA patients undergoing non-cardiac surgery and 837 OSA patients undergoing cardiac surgery.

INTERVENTION

PAP therapy MAIN RESULTS: In patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a decreased risk of postoperative respiratory complications (2.3% vs 3.6%; RR: 0.72, 95% CI: 0.51-1.00, asymptotic P = 0.05) and unplanned ICU admission (0.12% vs 4.1%; RR: 0.44, 95% CI: 0.19-0.99, asymptotic P = 0.05). No significant differences were found for all-cause complications (11.6% vs 14.4%; RR: 0.89, 95% CI: 0.74-1.06, P = 0.18), postoperative cardiac and neurological complications, in-hospital length of stay, and in-hospital mortality between the two groups. In patients with OSA undergoing cardiac surgery, PAP therapy was associated with decreased postoperative cardiac complications (33.7% vs 50%; RR: 0.63, 95% CI: 0.51-0.77, P < 0.0001), and postoperative atrial fibrillation (40.1% vs 66.7%; RR: 0.59, 95% CI 0.45-0.77, P < 0.0001).

CONCLUSION

In patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a 28% reduction in the risk of postoperative respiratory complications and 56% reduction in unplanned ICU admission. In patients with OSA undergoing cardiac surgery, PAP therapy decreased the risk of postoperative cardiac complications and atrial fibrillation by 37% and 41%, respectively.

Improving Bed Utilization in a Cohort of Bariatric Surgical Patients Using a Perioperative Obstructive Sleep Apnea Treatment and Bed Triage Protocol

BACKGROUND

Postoperative bariatric management often includes high-intensity monitoring for respiratory complications since > 70% of patients have obstructive sleep apnea. Given the increasing number of bariatric surgeries, there is a need to determine safe and cost-effective processes for postoperative care.The objective of this study was to determine if a novel triage and perioperative management guideline reduces postoperative monitoring and costs following bariatric surgery.

METHODS

Using a pre-post design, this is a retrospective analysis of 501 patients who had bariatric surgery. Half the patients were managed with usual care, and the other half received obstructive sleep apnea screening and treatment of moderate/severe obstructive sleep apnea with perioperative continuous positive airway pressure. The intervention group was triaged preoperatively to a postoperative nursing location based on risk factors.

RESULTS

There were no significant differences in demographics, comorbidities, frequency, or severity of OSA between groups. In the intervention group, there were fewer admissions to the intensive care unit (2.0% vs 9.1%; p < 0.01) and high acuity unit (9.6% vs 18.3%; p < 0.01). The length of stay was shorter in the intervention group (1.3 vs 2.3 days; p < 0.01) with a 50% reduction in costs. There were no statistically significant differences in the incidence of postoperative respiratory and non-respiratory complications between the two groups.

CONCLUSIONS

Most postoperative bariatric surgery patients can be safely managed on the surgical ward with monitoring of routine vitals alone if patients with moderate/severe obstructive sleep apnea receive perioperative continuous positive airway pressure.